Commentary on Hayes <i>et al</i>. (2020): The harms of opioid dose escalation in the management of chronic non‐cancer pain
Bibliographic record
Abstract
Opioid dose escalation in the management of chronic non-cancer pain is associated with an increased risk for several opioid-related adverse outcomes. When prescribing opioids for chronic non-cancer pain, clinicians should establish goals with patients, consider how opioids will be discontinued and plan to monitor the patient's response to treatment. Concerning trends in opioid prescribing continue to devastate global harm reduction efforts targeted at reducing opioid-related morbidity and mortality 1-3. In addition to risks of opioid use disorder 4 and opioid overdose 5, a number of other harms have been identified as sequalae of long-term opioid use 6. Due to their potent central nervous system depressant effects, chronic opioid use can lead to myriad medical sequalae, including cognitive dysfunction, nausea and vomiting, constipation, pruritus/itching, sedation/drowsiness and hypogonadism 7. Nevertheless, opioids are considered the mainstay of pain management. While opioids are frequently prescribed for the treatment of acute pain and cancer-related pain 8, 9, there is less consistent evidence for their use in the treatment of chronic non-cancer pain 10, 11. As many individuals who develop opioid use disorders may do so in the context of prescription opioid use for chronic non-cancer pain 12, prescribing patterns may play a significant role in the development of opioid-related problems in this population. This was demonstrated clearly by Hayes and colleagues’ 13 recent study, which arrived at an important and timely conclusion: escalating opioid dosing for the treatment of chronic non-cancer pain is associated with an increased risk for several opioid-related adverse outcomes. Given the dose–response relationship in their data, Hayes and colleagues posited that opioid-induced hyperalgesia—which is defined as a state of nociceptive sensitization caused by exposure to opioids—may mediate this observation, diminishing the perceived benefits and increasing the associated harms of opioid use for chronic non-cancer pain 14. To that end, recent literature suggests that hyperalgesia may be linked to the development of opioid tolerance 15. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile 15, and when combined with opioid tolerance both contribute to poorly controlled pain and dose escalation 15. Opioid-induced allodynia—a condition when a normally benign stimulus is perceived as pain—may further dampen the efficacy of opioid pharmacotherapy for chronic pain management, as it may dampen the perceived benefits of treatment from the patient's perspective 16. Practically speaking, non-opioid therapies remain preferred for treatment of chronic non-cancer pain, while opioids are reserved for scenarios when the benefits for pain and function are expected to outweigh the risks 6. Before initiating treatment, clinicians should establish goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks, and a plan to monitor the patient's response to treatment should be discussed at the outset 12. If opioids must be prescribed, several harm reduction strategies can be utilized, such as the avoidance of concurrent central nervous system depressants (such as other opioids or benzodiazepines) or the use of the lowest effective dose of opioids. In a similar vein, take-home naloxone can be co-prescribed to reduce the risk of overdose mortality 17. Evocative treatments, such as ketamine, have even begun to permeate into the emergency management of acute pain and may prevent the initiation of opioid prescribing 18. As Hayes and colleagues (13) identified, morbidity among individuals with chronic non-cancer pain who receive opioid therapy is high, but unless there are drastic changes in our approaches to the treatment of this subpopulation these statistics will not change. Taken together, these findings indicate that there is an urgent need for alternative evidence-based strategies to address chronic non-cancer pain. None.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".